Name: ________________________________________________________

Phone Number: _______________ Birthdate: __________________________

Address: _______________________________________________________

Resident of: (Check all that apply)

_____ Pickerington Local School District _____ Violet Township

High School:

_____ Pickerington Central _____ Pickerington North _____ Other

(Unweighted) Grade Point Average: __________

Parent/Guardian: ______________________________________________

Preferred Institute of Higher Learning: ______________________________

Intended Major: _______________________________________________

Interests and Extra Curricular Activities:

_________________________________________________________________

__________________________________________________________________

__________________________________________________________________

Community Service Experience:

__________________________________________________________________

___________________________________________________________________

____________________________________________________________________

 

I agree that all submitted information is true and accurate. 

 

Student Signature_________________________________________

 

Parent/Guardian Signature___________________________________

 

 

Committee Checklist:

 _____Application _____Essay _____ 2 Letters of Recommendation

_____Proof of Admission

 

Please submit your completed application and all supporting documents to: Violet Township Women’s League, P.O. Box 384, Pickerington, OH 43147, no later than March 23, 2012.